Krishnakumar Madhavan

A Randomized Controlled Trial Comparing Post-operative Pain in Single-Incision Laparoscopic Cholecystectomy Versus Conventional Laparoscopic Cholecystectomy

IntroductionAn increasing body of evidence is being published about single-incision laparoscopic cholecystectomy (SILC), but there are no well-powered trials with an adequate evaluation of post-operative pain. This randomized trial compares SILC against four-port laparoscopic cholecystectomy (LC) with post-operative pain as the primary endpoint.MethodsHundred patients were randomized to either SILC (nxa0=xa050) or LC (nxa0=xa050). Exclusion criteria were (1) Acute cholecystitis; (2) ASA 3 or above; (3) Bleeding disorders; and (4) Previous open upper abdominal surgery. Patients and post-operative assessors were blinded to the procedure performed. The site and severity of pain were compared at 4xa0h, 24xa0h, 14xa0days and 6xa0months post-procedure using the visual analog scale; non-inferiority was assumed when the lower boundary of the 95xa0% confidence interval of the difference was above −1 and superiority when pxa0≤xa00.05.ResultsThe study arms were demographically similar. At 24xa0h post-procedure, SILC was associated with less pain at extra-umbilical sites (rest: pxa0=xa00.004; movement: pxa0=xa00.008). Pain data were inconclusive at 24xa0h at the umbilical site on movement; SILC was otherwise non-inferior for pain at all other points. Operating duration was longer in SILC (79.46 vs 58.88xa0min, pxa0=xa00.003). 8xa0% of patients in each arm suffered complications (pxa0=xa01.000). Re-intervention rates, analgesic use, return to function, and patient satisfaction did not differ significantly.ConclusionsSILC has improved short-term pain outcomes compared to LC and is not inferior in both short-term and long-term pain outcomes. The operating time is longer, but remains feasible in routine surgical practice.

Outcomes of resection of giant hepatocellular carcinoma in a tertiary institution: does size matter?

BACKGROUNDnThe surgical management of giant hepatocellular carcinoma (G-HCC), or HCC of ≥10 cm in diameter, remains controversial. The aim of this study was to compare the outcomes of surgical resection of, respectively, G-HCC and small HCC (S-HCC), or HCC measuring <10 cm.nnnMETHODSnA retrospective review of all patients (n = 86) diagnosed with HCC and submitted to resection in a tertiary hospital during the period from January 2007 to June 2012 was conducted. Overall survival (OS), recurrence rates and perioperative mortality at 30 days were compared between patients with, respectively, G-HCC and S-HCC. Prognostic factors for OS were analysed.nnnRESULTSnThe sample included 23 patients with G-HCC (26.7%) and 63 with S-HCC (73.3%) based on histological tumour size. Patient demographics and comorbidities were comparable. Median OS was 39.0 months in patients with G-HCC and 65.0 months in patients with S-HCC (P = 0.213). Although size did not affect OS in this cohort, the presence of satellite lesions [hazard ratio (HR) 3.70, P = 0.012] and perioperative blood transfusion (HR 2.85, P = 0.015) were negative predictors for OS.nnnCONCLUSIONSnSurgical resection of G-HCC provides OS comparable with that after resection of S-HCC.

Metabolic syndrome after a liver transplantation in an Asian population

BACKGROUNDnWith improvements in patient survival after a liver transplantation (LT), long-term sequelae such as metabolic syndrome (MS) have become increasingly common. This study aims to characterize the prevalence, associations and long-term outcomes of post-LTMS and its components in an Asian population.nnnMETHODSnA retrospective review of all adult patients who underwent LT at the National University Health System Singapore between December 1996 and May 2012 was performed. MS was defined using the Adult Treatment Panel (ATP) III criteria modified for an Asian population.nnnRESULTSnThe median age of this cohort of 90 patients was 50.0 (16.0-67.0) years, with a median follow-up duration of 60.0 (7.0-192.0) months. The prevalence of post-LTMS was 35.6%, diabetes mellitus (DM) 51.1%, hypertension 60.0%, obesity 26.7% and dyslipidaemia 46.7%. On univariate analysis, factors significantly associated with post-LT MS include female gender (Pxa0=xa00.066), pre-LT respiratory comorbidities (Pxa0=xa00.038), pre-LT obesity (Pxa0=xa00.014), pre-LTDM (Pxa0<xa00.001), pre-LT hypertension (Pxa0=xa00.039), pre-LTMS (Pxa0<xa00.001), prednisolone use ≥24xa0months (Pxa0=xa00.005) and mycophenolate mofetil use ≥24xa0months (Pxa0=xa00.035). On multivariate analysis, independent associations of post-LT MS were pre-LTDM (Pxa0=xa00.011) and pre-LTMS (Pxa0=xa00.024). There was no difference in long-term survival of patients with and without post-LTMS (P = 0.425).nnnCONCLUSIONnIn conclusion, pre-LT components of the MS and the use of certain immunosuppressants are related to developing post-LTMS.

Greater hypertrophy can be achieved with associating liver partition with portal vein ligation for staged hepatectomy compared to conventional staged hepatectomy, but with a higher price to pay?

BACKGROUNDnAssociating liver partition with portal vein ligation for staged hepatectomy (ALPPS) and conventional staged hepatectomy (CSH) are options for patients with unresectable liver tumors due to insufficient future liver remnant (FLR).nnnMETHODSnA retrospective comparison of clinical data, liver volumetry and surgical outcomes between 10 ALPPS and 29 CSH patients was performed.nnnRESULTSnPatient demographics and disease characteristics were similar between both groups. ALPPS induced superior FLR growth (ALPPS vs. CSH, 48.1% (IQR 39.4-96.9%) vs. 11.8% (IQR 4.3-41.9%), pxa0=xa00.013). However, post-operative day 5 international normalized ratio (INR) (ALPPS vs. CSH, 1.6 (IQR 1.5-1.8) vs. 1.4 (IQR 1.3-1.6), pxa0=xa00.015) and rate of post-hepatectomy liver failure (ALPPS vs. CSH, 25 vs. 0%, pxa0=xa00.032) was higher in the ALPPS group. 90-day mortality (ALPPS vs. CSH, 12.5% vs. 0%, pxa0=xa00.320) was similar in both groups.nnnCONCLUSIONnALPPS was superior in inducing FLR growth but associated with increased post-hepatectomy liver failure compared to CSH.

ALPPS for Hepatocellular Carcinoma Is Associated with Decreased Liver Remnant Growth

BackgroundAssociating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been widely described for colorectal liver metastases with insufficient future liver remnant (FLR). However, its role in hepatocellular carcinoma (HCC) remains poorly defined and not widely accepted.MethodsA retrospective comparison of clinical data, liver volumetry, histological characteristics, and surgical outcomes between nine HCC and four non-HCC patients who underwent ALPPS was performed.ResultsPatients with HCC were more likely to have histological evidence of hepatic fibrosis (HCC vs. non-HCC, 66.7 vs. 0%, pu2009=u20090.049). Baseline demographic and disease characteristics were otherwise comparable between both groups. FLR growth after ALPPS-Stage 1 was significantly less in HCC patients (HCC vs. non-HCC, 154.5 vs. 251.0xa0ml, pu2009=u20090.012). FLR growth was also significantly decreased in patients with hepatic fibrosis (fibrosis vs. non-fibrosis, 157.5 vs. 247.5xa0ml, pu2009=u20090.033). There was no difference in post-hepatectomy liver failure (HCC vs. non-HCC, 28.6 vs. 25%, pu2009=u20090.721) or 90-day mortality (HCC vs. non-HCC, 11.1 vs. 0%, pu2009=u2009NS).DiscussionIn our study, HCC patients demonstrated significantly less FLR growth after ALPPS-Stage 1 compared to non-HCC patients. Hepatic fibrosis was also found to negatively impact FLR growth. When considering suitability for ALPPS, patients with HCC may benefit from additional pre-operative assessment of fibrosis.

Same admission laparoscopic cholecystectomy for acute cholecystitis: is the “golden 72 hours” rule still relevant?

BACKGROUNDnStudies have shown that same admission laparoscopic cholecystectomy (SALC) is superior to delayed laparoscopic cholecystectomy for acute cholecystitis (AC). While some proposed agolden 72-hour for SALC, the optimal timing remains controversial. The aim of the study was to compare the outcomes of SALC in AC patients with different time intervals from symptom onset.nnnMETHODSnA retrospective analysis of 311 patients who underwent SALC for AC from June 2010-June 2015 was performed. Patients were divided into three groups based on the time interval between symptom onset and surgery: <4 days (E-SALC), 4-7 days (M-SALC), >7 (L-SALC).nnnRESULTSnThe mean duration of symptoms was 2(1-3), 5(4-7) and 9 (8-13) days for E-SALC, M-SALC and L-SALC, respectively (pxa0<xa00.001). Conversion rates were higher in the L-SALC group [E-SALC, 8.2% vs M-SALC, 9.6% vs L-SALC, 21.4%] (pxa0=xa00.048). The total length of stay was longer in patients with longer symptom duration [E-SALC, 4 (2-33) vs M-SALC, 2 (2-23) vs L-SALC, 7 (2-49)] (pxa0<xa00.001).nnnCONCLUSIONnPatients with AC presenting beyond 7 days of symptoms have higher conversion rates and longer length of stay associated with SALC. However, patients with less than a week of symptoms should be offered SALC.

Bridging therapies to liver transplantation for hepatocellular carcinoma: A bridge to nowhere?

Backgrounds/Aims Liver Transplantation (LT) is a recognized treatment for Hepatocellular Carcinoma (HCC). The role of Bridging Therapies (BT) remains controversial. Methods From January 2001 to October 2012, 192 patients were referred to the National University Hospital, Singapore for consideration of LT for HCC. Sixty-five patients (33.8%) were found suitable for transplant and were placed on the waitlist. Analysis was performed in these patients. Results The most common etiology of HCC was Hepatitis B (n=28, 43.1%). Thirty-six patients (55.4%) received BT. Seventeen patients (47.2%) received TACE only, while 10 patients (27.8%) received radiofrequency ablation (RFA) only. The remaining patients received a combination of transarterial chemoembolization (TACE) and RFA. Baseline tumor and patient characteristics were comparable between the two groups. The overall dropout rate was 44.4% and 31.0% in the BT and non-BT groups, respectively (p=0.269). The dropout rate due to disease progression beyond criteria was 6.9% (n=2) in the non-bridged group and 22.2% (n=8) in the bridged group (p=0.089). Thirty-nine patients (60%) underwent LT, of which all patients who underwent Living Donor LT did not receive BT (n=4, 21.1%, p=0.030). The median time to LT was 180 days (range, 20–558 days) in the non-BT group and 291 days (range, 17–844 days) in the BT group (p=0.214). There was no difference in survival or recurrence between the BT and non-BT groups (p=0.862). Conclusions BT does not influence the dropout rate or survival after LT but it should be considered in patients who are on the waitlist for more than 6 months.

Delayed Presentation of Acute Cholecystitis: Comparative Outcomes of Same-Admission Versus Delayed Laparoscopic Cholecystectomy

IntroductionStudies have shown that same-admission laparoscopic cholecystectomy (SALC) is superior to delayed laparoscopic cholecystectomy (DLC) for acute cholecystitis (AC). However, no studies have compared both modalities in patients with delayed presentation. The aim of the study was to compare outcomes between SALC and DLC in AC patients with more than 7-day symptom duration.MethodsA retrospective analysis of 83 AC patients who underwent LC after presenting with >7xa0days of symptoms from June 2010 to June 2015 was performed. Patients were divided into L-SALC and L-DLC, defined as LC performed within the same admission and between 4 and 24xa0weeks after discharge, respectively. Peri-operative outcomes were evaluated.ResultsIn L-SALC patients, the intra-operative severity was higher (pu2009<u20090.001) and median operative time was longer (L-SALC, 107xa0min (46–220) vs L-DLC, 95xa0mins (25–186)) (pu2009=u20090.048). Conversion rates were also higher in L-SALC than that in L-DLC (L-SALC, 21.4% vs L-DLC, 4.9%) (pu2009=u20090.048). While post-operative morbidity was similar, L-SALC was associated with a longer post-operative length of stay as compared to L-DLC (L-SALC, 2 (1–17) vs L-DLC, 1 (1–6)) (pu2009<u20090.001).ConclusionDLC provides lower conversion rates and shorter length of stay in AC patients presenting beyond 7xa0days of symptoms. This group of patients should be offered DLC.

A predictive nomogram to identify factors influencing the success of a concomitant laparoscopic cholecystectomy with common bile duct exploration for choledocholithiasis

BACKGROUNDnSingle-staged laparoscopic common bile duct exploration (LCBDE) offers clear benefits in terms of cost and shorter hospitalization stays. However, a failed LCBDE requiring conversion to open surgery is associated with increased morbidity. This study reviewed the factors determining success of LCBDE, and created a predictive nomogram to stratify patients for the procedure.nnnMETHODSnA retrospective analysis of 109 patients who underwent LCBDE was performed. A nomogram was developed from factors significantly associated with conversion to open surgery and validated.nnnRESULTSnSixty-two patients underwent a successful LCBDE, while 47 patients required a conversion to open CBDE. The presence of underlying cholangitis (crude OR 2.70, 95% CI: 1.12-6.56, pxa0=xa00.017), together with its subsequent interventions, seemed to adversely increase the rate of conversion to open surgery. The predictive factors included in the nomogram for a failed laparoscopic CBDE included prior antibiotic use (adjusted OR (AOR) 2.98, 95% CI: 1.17-7.57, pxa0=xa00.022), previous ERCP (AOR 4.99, 95% CI: 2.02-12.36, pxa0=xa00.001) and abnormal biliary anatomy (AOR 9.37, 95% CI: 2.18-40.20, pxa0=xa00.003).nnnCONCLUSIONnLCBDE is useful for the treatment of choledocholithiasis. However, patients who were predicted to have an elevated risk for open conversion might not be ideal candidates for the procedure.